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Understanding fear in school children
Musleh Uddin Kalar 1*, Syed M. Mustahsan 2, Maroof Ali 2, Kiran Fatima 2, Khalil
Farooque 2, Marzia Batool 2, Syed M. Haider 2, Fatima Feroz 2
1
Senior Registrar MBBS, MPH, (USA). Department of Community Health Sciences, Karachi Medical &
Dental College, Pakistan
2
Research Associate MBBS, Dept. of Community Health Sciences, SMC, Dow University of Health Sciences,
Pakistan
* Corresponding Author: Musleh Uddin Kalar; MBBS, MPH, (USA)
Senior Registrar, Department of Community Health Sciences
Karachi Medical & Dental College, Pakistan
E-mail: [email protected] | Phone: 9221 03312587070 | Fax: 009221 36675655
Abstract
Introduction: Fear is an intense aversion to or apprehension of a person, place, activity, event,
or object that causes emotional distress and often avoidance behavior. Recent studies implicate
the prelimbic cortex in fear expression as well, by way of its connection to the basal and then to
central nucleus of amygdale.
Objective: The objective of this study was to determine the frequency of fear in school children.
Methods: This was a comparative cross sectional study which was conducted in a private
school. School children of 7-12 years of age were selected and the sampling technique was nonprobability convenient sampling. Fear Survey Schedule For Children – Revised (FSSC-R)
questionnaire was administered to indicate the level of fear. Multiple response analysis was
conducted to present overall frequency of fear. Logistic regression was conducted to assess the
predictors for the dependent variable of fear. Independent sample t- test was performed to assess
the normal distribution of fear.
Results: Most of the students feared from failing in their test (62.3%) proceeded by fear from
electricity (59.3%) and fear from wild animals (57.6%). Mean fear scores for females (9.40 ±
22.7) were higher than that of males fear scores (6.14 ± 22.7). Independent sample t-test showed
significant effect of gender, t(179) = -8.0, p < 0.0001, with females having higher scores than
males. Logistic regression showed the odds of sensitivity of fear were 5.64 times higher for
females than they were for males. For males, the odds were 1.06, and for females the odds were
5.98.
Study Limitation: Data was only collected from medium class students of 9 years of age.
Conclusion: Fears are a normal part of development, fears of children are realistic and most of
them imaginary.
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Key words: Fear-provoking cognitions, gender differences, Fear Survey Schedule – Revised
(FSSC-R), school children, optimistic statements
Introduction
Fear is an intense aversion to or apprehension of a person, place, activity, event, or object that
causes emotional distress and often avoidance behavior.1 Research in medical science revealed
that amygdala of the brain is primarily responsible for the conditioning of fear through sensory
system of the body and the central nucleus of amygdala controls defensive behavior (freezing),
autonomic and endocrine responses. Recent studies implicate the prelimbic cortex in fear
expression as well, by way of its connection to the basal and then to central nucleus of
amygdale.2 It is especially important to identify the possible fears of school children when
caring. School children have hospital related fears because of their developmental stage. They
are not able to separate reality from the imaginary and their ability to express and cope with their
fears is limited.3 Dental fears have multifactorial origins which are broadly divided into personal
characteristics, environmental factors, or situational factors. Most of the existing literature on
factors affecting dental fear and behavior focuses on school children as they most often present
with behavior problems. However, school-aged child through adolescence can also present with
behavior problems where communication cannot be established by the clinician. Though
personality characteristics are said to influence dental fear and behavior the most, they are also
strongly affected by social and family environments.4 A frequently used self-report instrument to
assess for specific phobia in youths is the Fear Survey Schedule for Children-Revised (FSSC-R).
The FSSC-R consists of 80 items assessing a broad range of fears out of which five common fear
factors emerge: fear of danger and death, failure and criticism, the unknown, small animals and
medical fears. The FSSC-R has to date been extensively tested for reliability and validity and
there are extensive normative data available, also the instrument seems to have good
discriminant properties to differentiate children with different types of specific phobias.5 It is
formulated to specify certain fear sensitivities in children and adolescents, as a tool to pick out
fearful children for prevention and treatment investigation and analysis and as a pre and post
therapy studies measure with children and adolescents.6 Factor analytic studies have revealed
that the FSSC-R contains five factors; fear of trauma and disasters (eg, bomb blast, fire injury
etc), fear of animals (like snake), fear of loneliness and strangers (eg, alone in crowd), fear of
criticism (eg, dress different from others) and fear of hospital and its instruments (eg, injections,
nurses). It categorizes the fear in children on a 3 point scale (none, some and a lot). The initial
studies have reported that young children are more fearful than older children and adolescence.
Previous researches has shown that children are more fearful of trauma and disasters which
causes physical injury like being hit by a car, bomb blasts, terrorists. Another study has reported
that the five target fears (“Not being able to breathe,” “Being hit by a car or truck”, “Falling from
high places”, “Bombing attacks or being invaded”, and “Fire or getting burned”) were listed in
the top ten of the most common fears for the children.7 This research is conducted to analyze the
rate of fear factor in children of our society and to explore the most common stimuli and the
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most frequent factor which causes fear in our children. The objective of this study was to
determine the frequency of fear in school children.
Materials and Methods
Study design and study cases
A comparative cross sectional study was conducted in a private school of Karachi, Pakistan from
January 2013 till March 2013. The participants were school children of 7-12 years of age and
were selected on the basis of non probability convenient sampling.
Sample Size
The sample size calculation was done using the W.H.O. software for “Sample Size Calculation”
edited by L. Lemeshow and S. K. Lwanga, where α = 5%, 1- β = 90, Po = 0.50, Pa = 0.40, n
(sample size) = 211. The researcher recruited 248 subjects to avoid the chances of type 2 error.
Inclusion/Exclusion Criteria
Children included in the study had vaccination status according to the Expanded Program of
Immunization of Pakistan and had no history of chronic illnesses. Children having repeated
hospitalization were excluded.
Administration
Fear Survey Schedule For Children – Revised (FSSC-R) questionnaire was administered and
school children are asked to indicate their level of fear to various stimuli and situations on a 3-point
scale: ‘none’, ‘some’, ‘a lot’. This took place in the children’s classrooms with the teacher and a
research assistant present to provide assistance, if necessary, and to ensure independent responding.
Confidentiality
The data were collected on the questionnaire without the names of the participants so that
anonymity could be maintained.
Fear Survey Schedule For Children – Revised (FSSC-R) Construct and Aims
The FSSC-R is intended to measure the construct of fear in children and adolescents. It is
designed (1) as an ipsative instrument to identify specific fear sensitivities in individual children
and adolescents, (2) as a normative instrument for selecting fearful children and adolescents for
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prevention and treatment trials and (3) as a pre-treatment and post-treatment measure in therapy
outcome studies with youths. It has been used in specific feared situations or objects that lead to
avoidance behaviors in youths with specific phobias and social phobias.8
Test Construction and Description
The FSSC-R is a widely used self-report measure of children and adolescents’ fears. The
instrument, a revision of Scherer and Nakamura’s original Fear Survey Schedule for Children,
contains 80 items that are each rated on a three-point scale (none, some, a lot).9 A total
fearfulness score can be obtained, as can five subscale scores based on a factor analysis of the
items. In addition, the number of intense fears can be indicated (i.e., the number of fears
endorsed ‘a lot’), as can the most prevalent fears for a given child/adolescent or group of
children and adolescents (i.e., boys, preadolescents, school phobic youngsters, etc.).10
Factor Structure
The FSSC-R possesses a relatively robust factor structure that has been replicated across sex, age
and nationality.11 Principal component analysis with varimax rotation was used to determine the
original factor structure, and confirmatory factor analysis procedures have been used to validate
the structure in subsequent studies. The five factors are entitled as (‘Making mistakes’ and
‘Being teased’), The Unknown (e.g. ‘Dark places’ and ‘Ghosts or spooky things’), Minor Injury
and Small Animals (e.g. ‘Snakes’ and ‘Getting a cut or injury’), Danger and Death (e.g. ‘Being
hit by a car or truck’ and ‘Not being able to breathe’) and Medical Fears (e.g. ‘Having to go to
the hospital’ and ‘Getting a shot from the nurse or doctor’). The factor structure has been related
meaningfully to different types of clinical phobia, including animal phobias, natural
environment/situational phobias, social phobias and injection/illness phobias.12,13
Reliability
The reliability of the FSSC-R total fearfulness score and the factor subscale scores has been
examined in three principal ways: internal consistency coefficients, test–retest reliabilities and
stability of scores over time. Cronbach’s alpha coefficients for the total fearfulness score have
consistently been reported to be above 0.90. Test–retest reliability for overall fearfulness has
been estimated to be 0.82. Factor subscale test–retest reliabilities have ranged from 0.70 to 0.87
over three months.14,15
Validity
The validity of the FSSC-R has been demonstrated in a number of ways. In the initial studies,
girls were found to report higher levels of fearfulness than boys and younger children were
shown to report higher levels of fearfulness than older children. These findings are consistent
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with the literature on sex-related fears in adults and developmental features of fear and related
constructs in children.15 Finally, the FSSC-R has been used to establish treatment efficacy in
major outcome studies with fearful and anxious children and adolescents.16,17
Application
Norms for children and adolescents between 7 and 16 years of age from the United States and
Australia are available. Other studies have reported means and standard deviations for samples
from other countries (e.g. England, Netherlands, France, Germany, and Sweden). FSSC-R total
and subscale scores have been shown to decrease with age and across longer time intervals,
caution is required in interpreting changes due to prevention and treatment trials.18
Data Management and Statistical Analysis
The data was entered on Statistical Package for Social Sciences (SPSS) version 20 (SPSS, Inc.,
Chicago, IL, USA).and analyzed. A descriptive analysis was performed; continuous variable of
age and fear scores were presented as continuous variables. Categorical variable of gender and
FSSC-R variables were presented as proportions (%). Multiple Response Analysis was
conducted to present overall frequency of fear. (Table 1) Binary logistic regression analysis was
conducted to assess the predictors for the dependent variable of fear, with a threshold for the
selection of p < 0.05. Independent variables were gender and age. Independent sample t- test was
performed to assess the normal distribution of dependent variable of fear. Assumptions were
made that two groups (males and females) have approximately equal variance on the dependent
variable of fear by conducting Levene’s test and the two groups are independent of one another.
Study Limitations
Although we have progressed through an advance prospective methodology but there are some
limitation of our study. Due to small sample size, we were unable to infer data from a large
population and majority of our data was from medium class students and were unable to judge
the psychological behavior of children as children may have some social desirability or some
type of negative information in their minds which can effects their fear beliefs but our study
showed that the mean age of fear was 9 years because this is an important developmental period
for simple phobias.
Ethical Considerations
The study protocol was approved by ethical review committee. Written informed consent was
taken from the participants before their enrolment in this study. The participants’ involvement in
this study was voluntary and no financial incentives were provided to any study participant.
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Results
Multiple Response Analysis
The mean age of school children was 9 years ± 1.81. Males were 67.2% and females were
32.8%. Multiple Response Frequencies procedure was used to display overall frequency of
school children who favored the dichotomous variable of “a lot for fear.” (Table 1, 2)
Independent sample t- test
Fear scores of males and females were compared. Descriptive statistics for the two groups
showed that the mean fear scores for females (9.40 ± 22.7) were higher than that of males fear
scores (6.14 ± 22.7). Levene’s Test for Equality of Variances showed the two groups had
approximately equal variance on the dependent variable of fear. The significance level is 0.06
indicating that the variances are approximately equal. There was a significant effect of gender,
t(179) = -8.0, p < 0.0001, with females having higher scores than males. (Table 3)
Binary logistic regression analysis
This model was used to predict the odds that a subject of a given gender will have fear
sensitivity. The odds prediction equation is if the subject is a male (gender = 1), then the ODDS
= e-1.671+1.731(1) = e0.06 = 1.06. That is, a male is only 1.06 times as likely to develop sensitivity of
fear. If the subject is a female (gender = 2) then the ODDS = e-1.67+1.73(2) = e1.79 = 5.98. That is, a
female is 5.98 times as likely to have sensitivity of fear. Odds were converted to probabilities.
For males Y = ODDS/1+ODDS = 1.06/1+1.06 = 0.51. That is our model predicts that 51% of
males have sensitivity of fear. For female Y = ODDS/1+ODDS = 5.98/1+5.98 = 0.85. That is,
our model predicts that 85% of female have sensitivity of fear. The variables in the equation
output also gives us the Exp(B) or the odds ratio predicted by the model. This odds ratio can be
computed by raising the base of the natural log to the bth power, where b is the slope from our
logistic regression equation. For our model e1.731 = 5.64. That tells us that the model predicts that
the odds of sensitivity of fear were 5.64 times higher for females than they were for males. For
males, the odds were 1.06, and for females the odds were 5.98. The odds ratio was 5.64/1.06 =
5.64. The Model summary shows the addition of gender and age as covariates in the analysis of
logistic regression. The R2 statistics was 0.11 indicating an 11% correlation of age and gender
with fear in children (Table 3).
Discussion
The FSSC-R was filled by 67.2% males and 32.8% females, total of 248 subjects. Out of these,
51% of males and 85% of females were sensitive to fear which indicates that females have 5.64
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times higher rate of fear than males. Our results showed that majority of the children were feared
from failing in a test (62.3%) followed by fear from getting a shock from electricity (59.3%),
bear or wolves (57.6%), falling from high places (56.8%), getting poor grades (56.4%) and
getting hit by a car or truck (56.4%). According to a survey conducted in Nepal, 2006 showed a
significant difference of fear factors between boys and girls as girls having high rate of fear than
boys (t=1.94, p=0.05)1 which is similar to the results obtained in our study with a significant
effect of gender. (t=-8.0, p=0.0001)19,20
Consistent with previous research, girls clearly displayed higher fear levels than boys. It is still
unclear what the origins of this marked gender difference in fearfulness are. The most plausible
explanations in the literature relate to biological (genetics and hormones) or socialization factors
(i.e., greater permission for girls to exhibit and report fears than boys).21-23 Individual difference
variables did not substantially mediate the effects of negative and positive information. Yet, it
should be noted that general fearfulness, anxiety sensitivity, and to a lesser extent trait anxiety
and behavioral inhibition, were already linked to fear of the beast, dogs, and other predators. At
the very least, this finding suggests that there is a group of anxiety-prone children who tend to
make inflated fear evaluations and become easily scared of a wide range of potentially
threatening stimuli.24
Future work should also examine whether the transmission of positive information can be
exploited therapeutically. Particularly in combination with exposure exercises, careful provision
of positive information could be a valuable clinical tool in correcting fear-provoking cognitions
and decreasing children’s level of fear overall. The present data as well as those obtained by
Field et al indicate that verbal information affects children’s fear evaluations. The results suggest
that adults can increase children’s fears by expressing negative ideas about certain stimuli and
situations as well as reduce or diminish fears in children through optimistic statements.25,26
Conclusion
Fears are a normal part of development but it can be a mind-killer, sapping all energy and willpower to take control of a situation and overcome it. Fears of children are realistic and most of
them imaginary. Children fears are learned. They are taught by their parents, teachers and
learned through experience. The responses of fear of school-age children include a wider range
of intrusive images and thoughts. School age play a big part in categorizing their perception of
reality. This may result in avoiding enjoyable conditions in their lives. The consequences of fear
include impaired mental and physical health, disturbed normal sleep patterns, lack of selfconfidence and all these interfere with less attention and concentration to studies because they
remain on alert for things happening around them. Fear can be released by counseling and
carrying out a continuous dialogue using children’s own language as sharing fears take away a
lot of scariness.
Considering the obtained results, the following significant points are of keen importance:
1) In comparison to boys, girls showed higher fear level concerning whole study.
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2) The most prevalent fears in school children are failing in a test, getting shock from electric
city, fear of beasts, falling from a high place, earth quack and fire burn.
Information of fear either positive or negative, greatly influence behavior of school children.
Recommendations
The ideal situation for a child is developed by their parents and teachers. Children should be
encouraged to develop their confidence against the fearful conditions. A scientific literature
should be developed to psychologically prepare the children and to implement the knowledge
that can able our children to cope up the fearful conditions.
Conflict of Interest: The authors declare that they have no competing interests.
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24. Merckelbach, H. and Muris, P. (2001) Specific Phobias, in Anxiety Disorders: An
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Table 1: Descriptive Statistics
Demographic profile and frequency of fear in school children
Characteristics
Mean ± SD or %
Age (years)
9 ± 1.81
Gender
Males (67.2%)
Table 2: Multiple Response Frequencies
Fear Variables
Bear or Wolves
Strange or Mean looking dogs
Being sent to the principal
Getting a report card
Failing a test
Getting poor grades
Getting punished by father
Getting hit by a car or truck
Fire getting burned
Getting a shock from electricity
Falling from high places
Burglar breaking into house
Death or dead people
Ghost or Spooky things
Earthquakes
Getting lost at a strange place
Not being able to breathe
N
136
109
123
97
147
133
116
133
125
140
134
100
105
100
128
120
119
Responses
Percent
2.3%
1.9%
2.1%
1.7%
2.5%
2.3%
2%
2.3%
2.1%
2.4%
2.3%
1.7%
1.8%
1.7%
2.2%
2%
2%
Percent of cases
57.6%
46.2%
52.1%
41.1%
62.3%
56.4%
49.2%
56.4%
53%
59.3%
56.8%
42.4%
44.5%
42.4%
54.2%
50.8%
50.4%
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Table 3: t-test & Logistic Regression
Independent Sample t test: Gender compared with Fear Scores Group Statistics
Characteristics
Gender
Male
Female
Equal variances assumed
Fear Scores Mean ± SD
Levene’s Test for equality of
variances
F
P
Fear
4.28
0.60
Probability of obesity - Binary Logistic Regression Analysis
Characteristics
Females (ref = male)
Age
Odds Ratio
5.64
0.97
Model summary
Step
-2 Log likelihood
1
221.338
95% CI
2.36, 13.47
0.92,1.03
Cox & Snell R Square
0.110
61.46 ± 22.7
94.04 ± 27.63
t-test for equality of Means
T
df
p
-8.07
179
0.0001
p-value
0.0001
0.44
Nagelkerke R Square
0.149
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